Transition of Care Document

Code	Activity	Start Date	End Date
266919005 (SNOMED)	Never smoker
Birth Sex	female
Sexual orientation	Unspecified
Gender identity	Identifies as Female

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	11/02/2023
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	10/24/2023
Localized obesity (disorder)	270486005(SNOMED)	Diagnosis	active	10/24/2023
Hypermobile Ehlers-Danlos syndrome (disorder)	30652003(SNOMED)	Diagnosis	active	10/24/2023
Lymphedema (disorder)	234097001(SNOMED)	Diagnosis	active	10/24/2023
Autoimmune disease (disorder)	85828009(SNOMED)	Problem	active
Depressive disorder (disorder)	35489007(SNOMED)	Problem	active
Plastic surgery self-referral (procedure)	183706004(SNOMED)	Problem	active
Psoriasis (disorder)	9014002(SNOMED)	Problem	active
History of skin disorder (situation)	161560005(SNOMED)	Problem	active

Substance	RxNorm	Reaction(s)	Severity	Status	Start Date
Sulfa (Sulfonamide Antibiotics)		Nausea, Anaphylaxis	unspecified	active

Medication	Generic Name	RxNorm	Strength	Strength Unit	Route	Dose	Dose Form	Frequency	Date Started	Date Ended	Status	Indication	Sig
metformin	metformin	861007	500	mg	Oral	1 Tablet	tablet	Twice a day	10/24/2023		active		Take 1 tablet orally twice a day with meals.

• I counseled the patient regarding the following: Skin care: Treatments include diet, exercise, and compression. If there is associated lymphedema, patients can benefit from manual lymphatic drainage. Liposuction has also been used to treat this condition. Expectations: Lipedema is a chronic condition characterized by excessive fat deposits on the legs, thighs, and buttocks. It can also affect the upper arms. The condition can be painful and can cause easy bruising. The cause is unknown. It may be genetic and because the condition affects almost exclusively women, it has been postulated that hormones may play a role in development of the condition. Contact office if: Lipedema causes pain or discomfort. Lipedema is a chronic disease presenting in women during puberty or other times of hormonal, weight and/or shape change such as pregnancy or menopause, characterized by symmetric enlargement of nodular, painful deposition of inflamed and fibrotic subcutaneous adipose tissue. Lipedema was first named as a medical condition in 1940 at the Mayo Clinic1 and in Germany.2 The diagnosis of lipedema is largely clinical and based on criteria initially established in 1951 by Drs. Wold, Allen and Hines.3 Lipedema starts in the lower extremities leading to circumferential bilateral lower extremity enlargement typically seen extending from the below the umbilicus to the ankles resulting in edema, pain and bruising; with secondary lymphedema, fibrosis and spreading of abnormal tissues to the trunk and arms occurs during later stages. Unfortunately as the lipedema tissue grows, the deep fascia and muscle are also affected reducing the function of the lymphatic pump. Lipedema is a hereditary disease and recently the first mutated gene AKR1C1 was discovered resulting in a slower and less efficient reduction of progesterone to hydroxyprogesterone and increased subcutaneous fat deposition in variant carriers, confirming hormones as important in lipedema.4 Lipedema also clearly manifests as a connective tissue disorder characterized by loss of elasticity in the skin5 and the aorta,6 hypertrophic adipocytes, inflammatory cells, and dilated leaky blood and lymphatic vessels.7, 8 She has lipedema in her legs, arms and trunk that includes nodules and pain in these areas. Her hands, feet, and upper trunk have been spared. She has other signs of lipedema including a negative Stemmer’s sign and abnormal fat pad development, disproportion, pain and dysmobility. She also might be developing early stages of lipo-lymphedema and thus her lipedema needs to be treated.] She has tried conservative measures for many months and while conservative therapies can reduce swelling and pain for a short time, removing the diseased tissue with surgery is necessary to reduce symptoms and progression long-term. Lipedema is distinct from non-lipedema obesity, although some, not all, patients can be obese. The adipose tissue accumulation is bilateral and symmetrical in the extremities, with the feet and hands spared from lipedema fat accumulation unless there is loss of elasticity as in hypermobile Ehlers Danlos where the skin has lost elasticity and fat can grow on the hand (with or without obesity). A hallmark of earlier stages of lipedema is the discrepancy in fatty tissue of the extremities compared to the trunk. This is in contrast to the fat associated with lifestyle-induced obesity, which is usually global and proportionate, affecting the abdomen equal or greater than the hips. Women with lipedema find it difficult to lose weight before a needed surgery or other procedures. There is a significant number of women with lipedema who have failed bariatric surgery because they were already controlling their diet but just not losing weight.9-11 Besides the many painful nodules that women with lipedema have, studies indicate that women with lipedema do not have the muscle strength like people who have non-lipedema obesity, are subject to more injuries and have poorer functional capacity.12 Thus, to improve function and reduce pain, lipedema surgery is recommended.13 References 1. Allen EV, Hines EAJ. Lipedema of the legs: A syndrome characterised by fat legs and orthostatic edema. Proc Staff Meet Mayo Clin. 1940;15:184-187. 2. Moncorps C BG, Herteld F et al. xperimentelle untersuchungen zur frage akrozyanotischer zustandsbilder. Arch Derm Syph. 1940;186:209-215. 3. Wold LE, Hines EA, Jr., Allen EV. Lipedema of the legs; a syndrome characterized by fat legs and edema. Ann Intern Med. 1951;34:1243-1250. 4. Michelini S, Chiurazzi P, Marino V, et al. Aldo-Keto Reductase 1C1 (AKR1C1) as the First Mutated Gene in a Family with Nonsyndromic Primary Lipedema. International Journal of Molecular Sciences. 2020;21:6264. 5. Jagtman BA, Kuiper JP, Brakkee AJ. [Measurements of skin elasticity in patients with lipedema of the Moncorps "rusticanus" type]. Phlebologie. 1984;37:315-319. 6. Szolnoky G, Nemes A, Gavaller H, Forster T, Kemeny L. Lipedema is associated with increased aortic stiffness. Lymphology. 2012;45:71-79. 7. AL-Ghadban S, Cromer W, Allen M, et al. Dilated Blood and Lymphatic Microvessels, Angiogenesis, Increased Macrophages, and Adipocyte Hypertrophy in Lipedema Thigh Skin and Fat Tissue. Journal of Obesity. 2019. 8. Felmerer G, Stylianaki A, Hägerling R, et al. Adipose Tissue Hypertrophy, An Aberrant Biochemical Profile and Distinct Gene Expression in Lipedema. J Surg Res. 2020;253:294-303.:10.1016/j.jss.2020.1003.1055. 9. Bast JH, Ahmed L, Engdahl R. Lipedema in patients after bariatric surgery. Surg Obes Relat Dis. 2016;12:1131-1132. doi: 1110.1016/j.soard.2016.1104.1013. Epub 2016 Apr 1114. 10. Pouwels S, Huisman S, Smelt HJM, Said M, Smulders JF. Lipoedema in patients after bariatric surgery: report of two cases and review of literature. Clin Obes. 2018;8:147-150. doi: 110.1111/cob.12239. Epub 12018 Jan 12225. 11. Pouwels S, Smelt HJ, Said M, Smulders JF, Hoogbergen MM. Mobility Problems and Weight Regain by Misdiagnosed Lipoedema After Bariatric Surgery: Illustrating the Medical and Legal Aspects. Cureus. 2019;11:e5388. doi: 5310.7759/cureus.5388. 12. van Esch-Smeenge J, Damstra RJ, Hendrickx AA. Muscle strength and functional exercise capacity in patients with lipoedema and obesity: a comparative study. Journal of Lymphoedema. 2017;12:27-31. 13. Herbst KL, Kahn LA, Iker E, et al. Standard of care for lipedema in the United States. Phlebology 2021;28(2683555211015887):2683555211015887. [published Online First: 2021/05/30 06:00]

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Code	Site	Date Diagnosed	Status
Documentation of past medical history (procedure)			completed
Documentation of past medical history (procedure)			completed
Documentation of past medical history (procedure)			completed
Plastic surgery self-referral (procedure)
Documentation of past medical history (procedure)

Vital Sign	Measurement	Date Recorded
Body Height	70.5 in	Thu Nov 02 15:46:00 UTC 2023
Body Weight	196.0 lbs	Thu Nov 02 15:46:00 UTC 2023
Body Mass Index	27.7 kg/m2	Thu Nov 02 15:46:00 UTC 2023

Future visit PRN - Follow up PRN for: Preoperative Appointment, Discussion of Procedure, Additional Consultation, Preoperative Marking

Code	Detail	Instructions
861007	metformin 500 mg tablet	Take 1 tablet orally twice a day with meals.

Problem	Code	Type	Status	Date of Diagnosis	Date of Resolution
History of skin disorder (situation)	161560005	FINDING
Psoriasis (disorder)	9014002	FINDING
Depressive disorder (disorder)	35489007	FINDING
Autoimmune disease (disorder)	85828009	FINDING

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1.Lipedema Counseling - Lipedema

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Service provided at Jaime S. Schwartz, MD, 240 S La Cienega Blvd Ste 200, Beverly Hills, CA 902113324. Office phone number is 3108825454.

Encounter Diagnosis	Location	Date / Time	Type
Lipedema (E65)	Jaime S. Schwartz, MD	11/02/2023 21:30:00 UTC	99202

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This is a 58 year old female who is being seen for a lipedema consultation for lipedema affecting the legs, thighs, arms, abdomen, pubic area, buttocks, hip shelf, knees, and ankles. Legs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Yes - Bruising: Yes - Pain: Yes - Cuffing: starting on right leg - Dimpling: Yes Thighs: - Location: Anterior and Posterior - Tenderness: Yes - Lipomas: Yes - Bruising: Yes - Pain: Yes - Dimpling: Yes Arms: - Tenderness: No - Lipomas: Yes - Thickened Tender Subcutaneous Fat: No - Spongy Adipose Tissue: Yes Abdomen: - Tenderness: No - Lipomas: No - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Pubic Area: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: No - Spongy Adipose Tissue: Yes Buttocks: - Tenderness: No - Lipomas: No - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Hip Shelf: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes - Dimpling: Yes Knees: - Tenderness: Yes - Lipomas: Yes - Thickened Tender Subcutaneous Fat: Yes - Spongy Adipose Tissue: Yes Ankles: - Tenderness: No - Lipomas: No - Thickened Tender Subcutaneous Fat: No - Spongy Adipose Tissue: No Duration: 30 years Associated Diagnoses: Ehlers Danlos, Lipomas, Connective Tissue Disease, and postural orthostatic tachycardia syndrome (POTS) Similarly Affected Family Members: grandmother Pedicures: in certain areas Do You Wear Boots: No Lipedema Worsened By: in her 20's Swelling Occurs With: standing, sitting, end of day, and summer Previous Treatments: Elevation (better), Compression Garments for 12 weeks or more (better), Manual Lymphatic Drainage for 12 weeks or more (no change), Sequential Pumps for 12 week or more (no change), Diet (Anti-inflammatory (no change)), and vibration plate - temporarily Difficulty Walking: Yes Flexibility: Very Flexible Cooler Areas: hands and feet Easy Bruising: legs, thighs, calves, and arms Pain: all the time (Average Pain Score: 6 out of 10), with movement (Worst Pain: 9 out of 10), and when sleeping Ability to move a chair from one room to another: Without any difficulty Ability to bend down and pick up clothing from the floor: Without any difficulty Ability to to stand for one hour: Unable to do Ability to do chores such as vacuuming or yard work: With some difficulty Ability to push open a heavy door: With some difficulty Ability to exercise for an hour: With a little difficulty Ability to carry a heavy object (over 10 pounds /5 kg): With much difficulty Ability to stand up from an armless straight chair: Unable to do Ability to dress yourself, including tying shoelaces and buttoning your clothes: With a little difficulty Ability to able to dry your back with a towel: Without any difficulty The patient understands and agrees that they must continue wearing compression garments after their surgery.

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Care Team Member Name	Role	Identifier	location	Telecom
Jaime Schwartz	Doctor	1336397660	240 S La Cienega Blvd Ste 200, Beverly Hills, CA 902113324, US	3108825454

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